Monroeville Employee Forms and Benefits...
Click on the links below to download forms.

Full Time Employee Check List Employee Handbook and Safety Manual
Part Time Employee Check List Summer/Part-Time Employee Handbook
Change of Address Municipality Phone List
Important Phone Numbers Employee Vacation Carry-Over Request Form
Human Resource Info Form Employee Observation Report
Personal Budget Spreadsheet (Excel)
Credit Union

Darlene Cole - 412 856-3345, Elizabeth Sommer - 412 829-1539

Or by Email at


Credit Union Booklet (directory, info, etc.) Credit Union Deduction Form
Credit Union Enrollment Form Credit Union Xmas Deduction Form
Credit Union Loan Application Designation of Beneficiary Form
Employee Payroll and Benefits
W-4 (2021) Direct Deposit of Paycheck
W-4P (2021) Local Services Tax Refund Application
I-9, Employment Eligibility Verification Local Services Tax Exemption Certificate
Earned Income Tax Residency Certification
Form 1000 Hire Authorization and New Position Request (yellow sheet)
Form 2000 Employee Status Change Request/Notification (blue sheet)
Form 4000 Accident Report (orange sheet)
Form 5000 Leave Request (green sheet)
Form 6000 Approval of Overtime and Comp. Time Hours (pink sheet)
Form 7000 Request for Outside Employment
Form 8000 Bereavement Notification
Family Medical Leave Info & Forms
Employee Expense Form (1/5/2021)
Fill-in Employee Expense Form (Excel) (1/5/2021)
Leave Without Pay Form
Physician Certification for Family or Medical Leave
Continuing Education Approval and Refund Application
Professional Meeting/Seminar/Training Attendance Request
Payroll Deduction Form Police FOP Deduction Form
  Police Union Dues Deduction Form
  Police Flower Fund Deduction Form
Deferred Compensation
ICMA 457 Plan - Client Services 1-800-669-7400              
ICMA Retirement Plan Representative - Michael Losak - 1-800-290-7158
ICMA 457 Enrollment ICMA 457 Contribution
Website -
CLICK HERE to learn more about the ICMA-RC 457 Plan CLICK HERE for information on the Payroll Deducted Roth IRA
Janney Montgomery Scott LLC
Frank Burke - 412 562-8187 or 1-800-441-1514
457 American Funds Plan Enroll 457 Plan Salary Deferral
Nationwide 457 Plan - 1-877-677-3678
  Participation Agreement 457(b)
Disability Insurance Benefits  
Monroeville Short Term Disability Form Application for Disability Retirement
Life Insurance  
Aflac - Dan Marcin 412-826-1840
Colonial Life - 1-800-325-4368
Conseco - 1-800-283-8075
Group Insurance Enrollment Form Life Insurance Change Form
Standard Insurance Group Life Policy  
Police Pension - Frank Burke - 412 562-8187 or 1-800-441-1514
Non-Police Pension 1-800-622-7968
Application for Membership (Admin, Clerical, Public Works, Refuse, Library)
PMRS Notification of Change
Nomination of Beneficiaries/Instructions (Police only)
PMRS website -
Employee Pension Plan Summary (Non-Uniform)
Workers Compensation
Workers' Compensation Employee Notification
Form 4000, Accident Report  
Workers' Compensation Provider Panel  
Municipality of Monroeville - The Workforce Protocol
2630, Benefits, Monroeville Exempt and Non-Exempt Employees
2497, Benefits, Monroeville Exempt and Non-Exempt Employees
2459, Benefits, Monroeville Exempt and Non-Exempt Employees
2612, Benefits, Monroeville Exempt and Non-Exempt Employees
2198, Military Leave Policy
2715 Police Collective Bargaining Agreement
2716 SEIU Clerical Workers & TCO Collective Bargaining Agreement
2646, Public Works Collective Bargaining Agreement
2648 Refuse Workers Collective Bargaining Agreement
Library Personnel Policy Manual 2011
Health Care
New Health Insurance Marketplace Coverage Options & Your Health Coverage
Highmark Blue Cross/Blue Shield Member Service Questions 800-241-5704
Highmark 2016 Preventive Schedule
Highmark Enrollment Application PPO Blue 1500Q Benefits Grid 2021
Highmark Member Change Form Health Care Insurance Rebate Form
Medco Mail Order Pharmacy Handbook Prescription Reimbursement Form
Medco By Mail Order Form Blue Card WorldWide Info
Health Advocate 1-866-695-8622  
Dental        United Concordia  1-800-332-0366
Dental Enrollment/Change Form Concordia Network Dental Plan Policy
Concordia Dental Benefits Summary 2020 Concordia Dental ID Card Update
Health Savings Plans  RHS Plan - ICMA - 1-800-290-7158
VantageCare Retirement Health Savings Plan (RHS) Enrollment/Change Form
Vision     1-800-432-4966  
Vision Care (Admin, Clerical, Police, Library)
Group Vision Care Summary Vision Benefits of America Enrollment
Vision Care (Public Works, Refuse)
Vision Care Summary Vision Benefits of America Enrollment
Vision Care (All Employees)
TLC Vision Advantage Program